Medical Loss Ratio Guarantee Sample Clauses

Medical Loss Ratio Guarantee. (a) For each calendar quarter that this contract is in effect, effective with the quarter beginning April 1, 2005, if the Contractor's Medical Loss Ratio (MLR) is less than 82%, the Department will recover by deduction from future payments a percentage of the quarter's premium revenue equal to the difference between the reported MLR and 82%. (b) Medical Loss Ratio shall be calculated by dividing total hospital and medical expenses incurred in Illinois by premium revenue paid by the Department. Premium revenue for a quarter shall be the premium revenue accrued, including Hospital Delivery Case Rate Payments. Expenses reported as Incurred But Not Reported (IBNR) shall be subject to review by the Department for actuarial soundness. All elements of reports used to calculate MLR are subject to audit by the Department. Audits may be ordered by the Department within 30 days of Departmental receipt of each quarterly report, and audits shall encompass the total subject matter of that report. (c) Hospital and medical expenses are the incurred costs of providing direct care to Enrollees for Covered Services. Outreach and general education are not included in medical expenses. (d) At the end of the four quarters ending March 31, 2006, the Department will review the Contractor's MLR for the full four quarters and recover or reconcile previous recoveries so that the Department has recovered the percentage of the total premium revenue for the four quarters equal to the difference between the cumulative MLR below 82% and 82%. Reconciliation shall consist of payment by the Contractor of any difference below the annualized 82% MLR not previously deducted, or repayment to the Contractor of deductions over the annualized 82% MLR previously made by the Department. A similar reconciliation will be performed at the end of each four quarters or the termination of any contractual relationship between the parties. Notwithstanding the provisions of section 7.12(b), the Department may order an audit of the reporting for the full four quarters within 45 days of Departmental receipt of a cumulative report of the four quarters. (e) The Contractor shall report all information necessary to effectuate this section in a format and on a schedule consistent with NAIC guidelines. The Department may request additional supporting information necessary to effectuate this section, and the Contractor shall report this information to the Department in a timely manner. (f) For purposes of calculating...
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Medical Loss Ratio Guarantee. The FIDA Plan has a Target Medical Loss Ratio (TMLR) threshold of eighty-five (85) percent.
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Medical Loss Ratio Guarantee. Contractor has a Target Medical Loss Ratio of eighty-eight percent (88%). If the Medical Loss Ratio calculated as set forth below is less than the Target Medical Loss Ratio, Contractor shall refund to the State an amount equal to the difference between the calculated Medical Loss Ratio and the Target Medical Loss Ratio (expressed as a percentage) multiplied by the
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Medical Loss Ratio Guarantee. The Contractor has a Target Medical Loss Ratio of eighty-five percent (85%) for Demonstration Years 1 through 5, eighty-six percent (86%) for Demonstration Year 6, eighty- seven percent (87%) for Demonstration Year 7, and eighty-eight percent (88%) for Demonstration Year 8. As described below, any collected remittances would be distributed proportionally back to the Medicaid and Medicare programs on a percent of premium basis. If the Medical Loss Ratio calculated as set forth below is less than the Target Medical Loss Ratio, the Contractor shall refund to the Department and CMS an amount equal to the difference between the calculated Medical Loss Ratio and the Target Medical Loss Ratio (expressed as a percentage) multiplied by the Coverage Year Revenue. The Department and CMS shall calculate a Medical Loss Ratio for Enrollees under this Contract for each Coverage Year, and shall provide to the Contractor the amount to be refunded, if any, to the Department and CMS respectively. Any refunded amounts will be distributed back to the Medicaid and Medicare programs, with the amount to each payor based on the proportion between the Medicare and Medicaid Components. At the option of CMS and the Department, separately, any amount to be refunded may be recovered either by requiring the Contractor to make a payment or by an offset to future Capitation payment. The Medical Loss Ratio Calculation shall be determined as set forth below; however, the Department and CMS may adopt NAIC reporting standards and protocols after giving written notice to the Contractor. 4.3.1.1 For Demonstration Years 1 through 5, if a Contractor has an MLR below eighty-five percent (85%) of the joint Medicare and Medicaid payment to the Contractor, the Contractor must remit the amount by which the eighty-five percent (85%) threshold exceeds the Contractor’s actual MLR multiplied by the total Capitation Rate revenue of the contract. 4.3.1.2 For Demonstration Years 6 through 8, in addition to remitting the amount by which the eighty-five percent (85%) threshold exceeds the Contractor’s MLR multiplied by the total Capitation Rate revenue, the Contractor will also remit according to the following schedule: 4.3.1.2.1 In Demonstration Year 6, if the Contractor’s MLR is below eighty-six percent (86%) and above eighty-five percent (85%), the Contractor would remit fifty percent (50%) of the difference between its MLR and eighty-five percent (85%) multiplied by the total Capitation Rate revenue; 4.3.1...
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Medical Loss Ratio Guarantee. The Contractor has a Target Medical Loss Ratio of eighty-five percent (85%). If the Medical Loss Ratio calculated as set forth below is less than the Target Medical Loss Ratio, the Contractor shall refund to the Department and CMS an amount equal to the difference between the calculated Medical Loss Ratio and the Target Medical Loss Ratio (expressed as a percentage) multiplied by the Coverage Year Revenue. The Department and CMS shall calculate a Medical Loss Ratio for Enrollees under this Contract for each Coverage Year, and shall provide to the Contractor the amount to be refunded, if any, to the Department and CMS respectively. Any refunded amounts will be distributed back to the Medicaid and Medicare programs, with the amount to each payor based on the proportion between the Medicare and Medicaid Components. At the option of CMS and the Department, separately, any amount to be refunded may be recovered either by requiring the Contractor to make a payment or by an offset to future Capitation payment. The Medical Loss Ratio Calculation shall be determined as set forth below; however, the Department and CMS may adopt NAIC reporting standards and protocols after giving written notice to the Contractor. 4.3.1.1 The MLR will be based on 42 C.F.R. §§ 422.2400 et seq. and §§ 423.2400 et seq., except that the numerator in the MLR calculation will include: 4.3.1.1.1 All Covered Services required in the Demonstration under Section 2.4 and Appendix A; 4.3.1.1.2 Any services purchased in lieu of more costly Covered Services and consistent with the objectives of the MMAI;
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Medical Loss Ratio Guarantee. Contractor has a Target Medical Loss Ratio of eighty-eight percent (88%). If the Medical Loss Ratio calculated as set forth below is less than the Target Medical Loss Ratio, Contractor shall refund to the State an amount equal to the difference between the calculated Medical Loss Ratio and the Target Medical Loss Ratio (expressed as a percentage) multiplied by the Coverage Year Revenue. The Department shall prepare a Medical Loss Ratio Calculation which shall summarize Contractor’s Medical Loss Ratio for Enrollees under this Contract for each Coverage Year. The Medical Loss Ratio Calculation shall be determined as set forth below; however, the Department may adopt NAIC reporting standards and protocols after giving written notice to Contractor.
Sample 1
Medical Loss Ratio Guarantee. 7.10.1 Contractor shall calculate, and report to the Department, a medical loss ratio (MLR) for each calendar year (MLR reporting year), consistent with MLR standards in 42 CFR 438.8 (a). The MLR calculation shall be determined as set forth below; however, the Department may adopt NAIC reporting standards and protocols after giving written notice to Contractor. 7.10.2 For calendar years (MLR reporting years) 2018 through 2021, the minimum MLR is 85 percent (85%). Effective with calendar year (MLR reporting year) 2022, the minimum MLR is 88 percent (88%). The Department retains the right to adjust the minimum MLR in adherence to 42 CFS §438.8.
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Medical Loss Ratio Guarantee. 7.10.1 Contractor shall calculate, and report to the Department, a medical loss ratio (MLR) for each calendar year (MLR reporting year), consistent with MLR standards in 42 CFR 438.8 (a). The MLR calculation shall be determined as set forth below; however, the Department may adopt NAIC reporting standards and protocols after giving written notice to Contractor. 7.10.2 The minimum MLR is 85 percent (85%). The Department retains the right to adjust the minimum MLR in adherence to 42 CFS §438.8. 7.10.3 Contractor shall calculate the MLR for each Coverage Year as the ratio of the numerator (as defined in accordance with 42 CFR 438.8(e)) to the denominator (as defined in accordance with 42 CFR 438.8(f)).‌ 7.10.4 Contractor shall: 7.10.4.1 include each of Contractor’s expenses under only one (1) type of expense, unless a portion of the expense fits under the definition of, or criteria for, one (1) type of expense and the remainder fits into a different type of expense, in which case the expense must be prorated between types of expenses; and 7.10.4.2 report expenditures that benefit multiple contracts or populations, or contracts other than those being reported, on pro rata basis. 7.10.5 Contractor shall: 7.10.5.1 base expense allocation on a generally accepted accounting method that is expected to yield the most accurate results; 7.10.5.2 apportion shared expenses, including expenses under the terms of a management contract, pro rata to the contract incurring the expense; and‌ 7.10.5.3 ensure that those expenses that relate solely to the operation of a reporting entity, such as personnel costs associated with the adjusting and paying of claims, must be borne solely by the reporting entity and are not to be apportioned to the other entities.
Sample 1
Medical Loss Ratio Guarantee. Contractor has a Target Medical Loss Ratio of eighty-eight percent (88%). If the Medical Loss Ratio calculated as set forth below is less than the Target Medical Loss Ratio, Contractor shall refund to the State an amount equal to the difference between the calculated Medical Loss Ratio and the Target Medical Loss Ratio (expressed as a percentage) multiplied by the Coverage Year Revenue. The Department shall prepare a Medical Loss Ratio Calculation which shall summarize Contractor’s Medical Loss Ratio for Enrollees under this Contract for each Coverage Year. The Medical Loss Ratio Calculation shall be determined as set forth below; however, the Department will use best efforts to evaluate the use of the National Association of Insurance Commissioner (―NAIC‖) definition of medical loss ratio for the purpose of calculating the Medical Loss Ratio, with the goal being adoption of as much of the NAIC definition as is consistent with the Department’s policy goals and interests prior to the initial calculation of Contractor’s Medical Loss Ratio. In the event the Department adopts some or all of NAIC guidelines for the calculation of the Medical Loss Ratio, the Department shall notify Contractor in writing. Notwithstanding the foregoing and independent of such evaluation of the NAIC definition of medical loss ratio, prior to the initial calculation of Contractor’s Medical Loss Ratio, the parties will work in good faith to detail the basis of calculating the Medical Loss Ratio including establishing sample calculations to demonstrate what is included and excluded from the Medical Loss Ratio.
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Related to Medical Loss Ratio Guarantee

  • Subordinate Certificate Loss Coverage; Limited Guaranty Subject to subsection (c) below, prior to the later of the third Business Day prior to each Distribution Date or the related Determination Date, the Master Servicer shall determine whether it or any Sub-Servicer will be entitled to any reimbursement pursuant to Section 4.02(a) on such Distribution Date for Advances or Sub-Servicer Advances previously made, (which will not be Advances or Sub-Servicer Advances that were made with respect to delinquencies which were subsequently determined to be Excess Special Hazard Losses, Excess Fraud Losses, Excess Bankruptcy Losses or Extraordinary Losses) and, if so, the Master Servicer shall demand payment from Residential Funding of an amount equal to the amount of any Advances or Sub-Servicer Advances reimbursed pursuant to Section 4.02(a), to the extent such Advances or Sub-Servicer Advances have not been included in the amount of the Realized Loss in the related Mortgage Loan, and shall distribute the same to the Class B Certificateholders in the same manner as if such amount were to be distributed pursuant to Section 4.02(a).

  • Release of Subsidiary Guarantors from Guarantee (a) Notwithstanding any other provisions of this Indenture, the Guarantee of any Subsidiary Guarantor may be released upon the terms and subject to the conditions set forth in Section 11.02(b) and in this Section 14.04. Provided that no Default shall have occurred and shall be continuing under this Indenture, the Guarantee incurred by a Subsidiary Guarantor pursuant to this Article XIV shall be unconditionally released and discharged (i) automatically upon (A) any sale, exchange or transfer, whether by way of merger or otherwise, to any Person that is not an Affiliate of the Partnership, of all of the Partnership’s direct or indirect limited partnership or other equity interests in such Subsidiary Guarantor (provided such sale, exchange or transfer is not prohibited by this Indenture) or (B) the merger of such Subsidiary Guarantor into either of the Issuers or any other Subsidiary Guarantor or the liquidation and dissolution of such Subsidiary Guarantor (in each case to the extent not prohibited by this Indenture) or (ii) upon the Issuers’ delivery of a written notice to the Trustee of the release or discharge of all guarantees by such Subsidiary Guarantor of any Debt of the Issuers other than obligations arising under this Indenture and any Debt Securities issued hereunder, except a discharge or release by or as a result of payment under such guarantees. (b) The Trustee shall deliver an appropriate instrument evidencing any release of a Subsidiary Guarantor from the Guarantee upon receipt of a written request of the Issuers accompanied by an Officers’ Certificate and an Opinion of Counsel to the effect that the Subsidiary Guarantor is entitled to such release in accordance with the provisions of this Indenture. Any Subsidiary Guarantor not so released shall remain liable for the full amount of principal of (and premium, if any) and interest on the Debt Securities entitled to the benefits of the Guarantee as provided in this Indenture, subject to the limitations of Section 14.03.

  • Guarantors’ Rights of Subrogation, Contribution, Etc Until the Guaranteed Obligations shall have been indefeasibly paid in full, each Guarantor hereby waives any claim, right or remedy, direct or indirect, that such Guarantor now has or may hereafter have against Borrower or any other Guarantor or any of its assets in connection with this Guaranty or the performance by such Guarantor of its obligations hereunder, in each case whether such claim, right or remedy arises in equity, under contract, by statute, under common law or otherwise and including (a) any right of subrogation, reimbursement or indemnification that such Guarantor now has or may hereafter have against Borrower with respect to the Guaranteed Obligations, (b) any right to enforce, or to participate in, any claim, right or remedy that any Beneficiary now has or may hereafter have against Borrower, and (c) any benefit of, and any right to participate in, any collateral or security now or hereafter held by any Beneficiary. In addition, until the Guaranteed Obligations shall have been indefeasibly paid in full, each Guarantor shall withhold exercise of any right of contribution such Guarantor may have against any other guarantor (including any other Guarantor) of the Guaranteed Obligations, including any such right of contribution as contemplated by Section 7.2. Each Guarantor further agrees that, to the extent the waiver or agreement to withhold the exercise of its rights of subrogation, reimbursement, indemnification and contribution as set forth herein is found by a court of competent jurisdiction to be void or voidable for any reason, any rights of subrogation, reimbursement or indemnification such Guarantor may have against Borrower or against any collateral or security, and any rights of contribution such Guarantor may have against any such other guarantor, shall be junior and subordinate to any rights any Beneficiary may have against Borrower, to all right, title and interest any Beneficiary may have in any such collateral or security, and to any right any Beneficiary may have against such other guarantor. If any amount shall be paid to any Guarantor on account of any such subrogation, reimbursement, indemnification or contribution rights at any time when all Guaranteed Obligations shall not have been finally and indefeasibly paid in full, such amount shall be held in trust for Administrative Agent on behalf of Beneficiaries and shall forthwith be paid over to Administrative Agent for the benefit of Beneficiaries to be credited and applied against the Guaranteed Obligations, whether matured or unmatured, in accordance with the terms hereof.

  • Guarantee The Guarantor irrevocably and unconditionally agrees to pay in full to the Holders the Guarantee Payments (without duplication of amounts theretofore paid by the Issuer), as and when due, regardless of any defense, right of set-off or counterclaim that the Issuer may have or assert. The Guarantor's obligation to make a Guarantee Payment may be satisfied by direct payment of the required amounts by the Guarantor to the Holders or by causing the Issuer to pay such amounts to the Holders.

  • Limitation of Subsidiary Guarantor's Liability Each Subsidiary Guarantor and by its acceptance hereof each Holder of Securities hereby confirms that it is the intention of all such parties that the guarantee by such Subsidiary Guarantor pursuant to its Subsidiary Guarantee not constitute a fraudulent transfer or conveyance for purposes of any federal, state or foreign law. To effectuate the foregoing intention, the Holders of Securities and each Subsidiary Guarantor hereby irrevocably agree that the obligations of each Subsidiary Guarantor under its Subsidiary Guarantee shall be limited to the maximum amount as will, after giving effect to all other contingent and fixed liabilities of such Subsidiary Guarantor and after giving effect to any collections from or payments made by or on behalf of any other Subsidiary Guarantor in respect of the obligations of such other Subsidiary Guarantor under its Subsidiary Guarantee, result in the obligations of such Subsidiary Guarantor under the Subsidiary Guarantee not constituting a fraudulent conveyance or fraudulent transfer under federal, state or foreign law.

  • Waiver of Subrogation, Reimbursement and Contribution Notwithstanding anything to the contrary contained in this Guaranty, Guarantor hereby unconditionally and irrevocably waives, releases and abrogates any and all rights it may now or hereafter have under any agreement, at law or in equity (including, without limitation, any law subrogating the Guarantor to the rights of Lender), to assert any claim against or seek contribution, indemnification or any other form of reimbursement from Borrower or any other party liable for payment of any or all of the Guaranteed Obligations for any payment made by Guarantor under or in connection with this Guaranty or otherwise.

  • Money Back Guarantee If we provide a money back guarantee ("MBG") for your Service, it will begin on your Service Ready Date. During this MBG period you may cancel your Service and receive a full refund of all monthly, one-time and equipment charges paid to Verizon (provided you return all Equipment in good working condition). If you fail to return the Equipment, an unreturned Equipment fee will apply. ETFs will not apply to Service terminated within the MBG period. The MBG does not apply to customers who change between or renew bundle, monthly, term or other pricing plans. The MBG is limited to one per Subscriber per Service type per Service address.

  • Agreement to Guarantee The Guaranteeing Subsidiary hereby agrees to provide an unconditional Guarantee on the terms and subject to the conditions set forth in the Note Guarantee and in the Indenture including but not limited to Article 10 thereof.

  • Loss of Shared-Loss Coverage on Shared-Loss Loans The Receiver shall be relieved of its obligations with respect to a Shared-Loss Loan upon payment of a Foreclosure Loss amount, or a Short Sale Loss amount with respect to such Single Family Shared-Loss Loan, or upon the sale without FDIC consent of a Single Family Shared-Loss Loan by Assuming Institution to a person or entity that is not an Affiliate. The Assuming Institution shall provide the Receiver with timely notice of any such sale. Failure to administer any Shared-Loss Loan or Loans in accordance with Article III shall at the discretion of the Receiver constitute grounds for the loss of shared loss coverage with respect to such Shared-Loss Loan or Loans. Notwithstanding the foregoing, a sale of the Single Family Shared-Loss Loan, for purposes of this Section 2.7, shall not be deemed to have occurred as the result of (i) any change in the ownership or control of Assuming Institution or the transfer of any or all of the Single Family Shared-Loss Loan(s) to any Affiliate of Assuming Institution, (ii) a merger by Assuming Institution with or into any other entity, or (iii) a sale by Assuming Institution of all or substantially all of its assets.

  • Limitation on Subsidiary Guarantor Liability Each Subsidiary Guarantor, and by its acceptance of Notes, each Holder, hereby confirms that it is the intention of all such parties that the Subsidiary Guarantee of such Subsidiary Guarantor not constitute a fraudulent transfer or conveyance for purposes of Bankruptcy Law, the Uniform Fraudulent Conveyance Act, the Uniform Fraudulent Transfer Act or any similar federal or state law to the extent applicable to any Subsidiary Guarantee. To effectuate the foregoing intention, the Trustee, the Holders and the Subsidiary Guarantors hereby irrevocably agree that the obligations of such Subsidiary Guarantor will, after giving effect to such maximum amount and all other contingent and fixed liabilities of such Subsidiary Guarantor that are relevant under such laws, and after giving effect to any collections from, rights to receive contribution from or payments made by or on behalf of any other Subsidiary Guarantor in respect of the obligations of such other Subsidiary Guarantor under this Article Ten, result in the obligations of such Subsidiary Guarantor under its Subsidiary Guarantee not constituting a fraudulent transfer or conveyance. Each Subsidiary Guarantor that makes a payment for distribution under its Subsidiary Guarantee is entitled to a contribution from each other Subsidiary Guarantor in a pro rata amount based on the adjusted net assets of each Subsidiary Guarantor.

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